Pier Andrea Farneti

Minimally invasive aortic valve replacement via right anterior minithoracotomy: Early outcomes and midterm follow-up

FIGURE 1. A, Axial plane shows the right position of the aorta with respect t feasibility of cannulating the ascending aorta and replacing the aortic valve throu ment. AC, Aortic cannula; AT, aortic tourniquet; XC, crossclamp; LVV, left ven From the Department of Cardiothoracic Surgery, Fondazione G. Monasterio, CNR—Regione Toscana, Massa, Italy. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Jan 28, 2011; revisions received April 26, 2011; accepted for publication May 17, 2011; available ahead of print July 4, 2011. Address for reprints: Antonio Miceli, MD, Fondazione G. Monasterio, CNR-regione Toscana, 54100 Massa, Italy (E-mail: antoniomiceli79@alice.it). J Thorac Cardiovasc Surg 2011;142:1577-9 0022-5223/

Might type A acute dissection repair with the addition of a frozen elephant trunk improve long-term survival compared to standard repair?

36.00 Copyright 2011 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2011.05.011

Full sternotomy versus right anterior minithoracotomy for isolated aortic valve replacement in octogenarians: a propensity-matched study †

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with an acute type A dissection (TAAD) is a frozen elephant trunk in addition to standard aortic dissection repair advantageous in terms of improved long-term mortality and closure of the distal false lumen? Altogether more than 138 papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Jakob et al. (23 patients stented vs. 22 patients non-stented), showed similar early outcome but lower false lumen patency rate and lower need of reintervention in the stented group. Pochettino et al. (36 patients stented vs. 42 patients non-stented) reported higher circulatory arrest time and higher incidence of spinal cord and bowel ischemia but a lower false lumen patency rate in stented group. Uchida and co-workers (65 patients stented vs. 55 patients non-stented) reported similar early outcome but better long-term survival and freedom from aortic events in the stented group. Consecutively, Uchida et al. reported the follow-up of the stented group demonstring false lumen thrombosis in all patients one month postoperatively, and complete after three years. Sun and co-workers (107 patients operated with an hybrid approach) showed a hospital mortality of 4.67% and neurological complications rate of 5.6%. At follow-up (35+/-14 months), 95% of the patients had false lumen thrombosis and no distal reoperations were needed. We conclude that the frozen elephant trunk is still rarely adopted during TAAD repair. However, this procedure can be performed safely without increase the operative mortality and morbidity but with an overall higher cardiopulmonary bypass and circulatory arrest time. Spinal cord ischemia and malperfusion syndrome represents the main complications associated with this procedure. Despite few studies, this procedure seems to allow early thrombosis of the false lumen and a reduction of late thoraco-abdominal aneurysm formation and reoperations rate.

Nonthyroidal illness syndrome in off-pump coronary artery bypass grafting

OBJECTIVES Surgical aortic valve replacement (AVR) is increasingly performed in elderly patients with good perioperative outcomes and long-term survival, resulting in significant health-related quality-of-life benefits. This study aimed to evaluate the outcome of patients aged ≥ 80 years undergoing isolated AVR through a right anterior minithoracotomy (RAMT) and compare it with a full sternotomy (FS). METHODS Two hundred and eighty-three elderly patients aged 80 years or more underwent isolated AVR between February 2001 and September 2013. With propensity score matching (1 : 1), the outcomes of patients having minimally invasive surgery (RAMT) were compared with those in whom the FS approach had been employed (100 vs 100 patients). TAVRs and partial sternotomy cases were excluded from the analysis. RESULTS There were two conversions in the RAMT group. Operative times did not significantly differ in the two groups. Patients in the RAMT group received a larger-sized prosthesis (P < 0.001) and were more likely to receive sutureless valves (P < 0.001). Shorter time for extubation (P < 0.001) and shorter hospital length of stay (P = 0.005) were observed in the RAMT group. Zero vs 4 (4.0%) (P = 0.043) patients had postoperative stroke and 2 (2.0%) vs zero (P = 0.16) had a transient ischaemic attack in the RAMT versus FS group, respectively. We registered the same rate of permanent pacemaker implant (P = 0.47) and that of new-onset atrial fibrillation (P = 0.28) for both groups. Six patients died, with no significant difference for in-hospital mortality (P = 0.68). No variable had a statistically significant predictive value for in-hospital mortality. RAMT patients were more likely to be discharged home directly or via rehabilitation (P = 0.031). FS, along with four other factors, independently predicted longer hospital stay. Though the median follow-up duration was longer in the FS group (59 vs 24 months, P < 0.001), the two groups had similar survival rates at 5 years (80 vs 81%, P = 0.37). Ten factors were associated with long-term survival by Cox regression analysis, and RAMT had no statistical impact (P = 0.38). CONCLUSIONS Minimally invasive AVR through right anterior minithoracotomy can be safely performed in patients aged ≥80 years with acceptable morbidity and mortality rates. It is an expeditious and effective alternative to full sternotomy AVR and might be associated with lower postoperative stroke incidence, earlier extubation and shorter hospital stay.

Evaluation of platelet count after isolated biological aortic valve replacement with Freedom Solo bioprosthesis

BACKGROUND Cardiopulmonary bypass (CPB) is an established cause of nonthyroidal illness syndrome (NTIS). Off-pump coronary artery bypass (OPCAB) has been reported to be less invasive than coronary artery bypass grafting (CABG) with CPB. We prospectively evaluated thyroid metabolism in OPCAB patients. METHODS We analyzed free thyroid hormones (FT3 and FT4), thyroid-stimulating hormone (TSH), and reverse T3 (rT3) in 20 consecutive patients undergoing CABG surgery. Nine patients underwent CABG with CPB, and 11 underwent OPCAB. Blood samples were taken on admission, on the day of surgery (7:30 AM), after sternotomy, at the end of the operation, and at 2, 6, 12, 24, 36, 48, 72, 96, 120, and 144 hours postoperatively. The concentrations of FT3, FT4, and TSH were determined on each sample. Reverse T3 concentration was measured in 10 patients up to 48 hours and at 144 hours postoperatively. RESULTS Baseline, operative, and postoperative variables were similar in the two groups. FT3 concentration dropped significantly (p < 0.0001), reaching its lowest value 12 hours postoperatively. There were no significant differences between CPB and OPCAB patients. FT4 varied significantly in both groups (p < 0.0001), but remained in the normal range. TSH variation was not significant. rT3 concentration rose significantly (p = 0.0002) in both groups, peaking 24 hours after surgery. CONCLUSIONS. OPCAB induces a NTIS similar to that observed after CPB, probably due to the inhibition of T4 conversion to T3. This finding suggests that NTIS is a nonspecific response to stress. CPB should not be considered as the sole trigger of NTIS in cardiac surgical patients.

Reduction of blood coagulation and monocyte-platelet interaction following the use of a minimal extracorporeal circulation system (Synergy) in coronary artery bypass grafting (CABG).

OBJECTIVE The risk of thrombocytopenia in patients undergoing aortic valve replacement (AVR) with the Freedom Solo (FS) bioprosthesis is controversial. The aim of our study was to evaluate the postoperative evolution of platelet count and function after AVR in patients undergoing isolated biological AVR with FS. METHODS Between May 2005 and June 2010, 322 patients underwent isolated biological AVR. Of these, 116 patients received FS and were compared with 206 patients who received biological valves. Platelet count, mean platelet volume (MPV), and platelet distribution width (PDW) were evaluated at baseline (T0), first (T1), second (T2), and fifth (T3) postoperative days, respectively. RESULTS Overall in-hospital mortality was 1.5% with no difference between the two groups. Thirty-seven (11.5%) patients developed thrombocytopenia. FS implantation was associated with a higher incidence of thrombocytopenia compared with the control group (24.1% vs 4.4%, p<0.0001). Patients in the FS group showed a lower platelet count than the control group at T1 (99.4±38×10(3) μl(-1) vs 122.5±41.6×10(3) μl(-1), p<0.001), T2 (79.7±36.3×10(3) μl(-1) vs 122.5±43.3×10(3) μl(-1), p<0.001) and T3 (86.6±57.4×10(3) μl(-1) vs 158.4±55.8×10(3) μl(-1), p<0.001). Moreover, the FS group also had a higher MPV (11.6±0.9 fl vs 11±1 fl, p<0.001) and higher PDW (15.1±2.3 fl vs 13.9±2.1 fl, p<0.001) at T3. In a multivariable analysis, FS (p<0.0001), body surface area (p<0.0001), cardiopulmonary bypass time (p=0.003), and lower preoperative platelet counts (p=0.006) were independent predictors of thrombocytopenia. CONCLUSIONS The FS valve might increase the risk of thrombocytopenia and platelet activation, in the absence of adverse clinical events. Prospective randomized studies on platelet function need to confirm our data.

Minimally invasive aortic valve replacement: 12-year single center experience

Cardiovascular surgery with cardiopulmonary bypass (CPB) induces activation of blood coagulation and systemic inflammation involved in post-operative complications. Our study evaluated the impact of the minimal extracorporeal circulation (mini-CPB) system (Synergy®, Sorin Group) on these functional aspects. Twenty patients were randomly assigned to standard CPB (n=10) or to Synergy (n=10). Platelet expression of PAC-1, and monocyte/granulocyte-platelet conjugates were evaluated by flow cytometry. A leukocyte-platelet adhesion index was calculated after cell number normalization. ELISAs were performed to measure IL-6 and TNF-α, thrombin-antithrombin III complexes (TAT), prothrombin fragments (F1+2), β-thromboglobulin (β-TG) and sP-selectin (sCD62P). Blood samples were drawn at the time of anesthesia (T1), at the end of CPB (T2), and at 4 (T3) and 24 hours (T4) after weaning from CPB. All patients were similar for clinical characteristics. When compared to standard CPB, the Synergy showed lower levels of the monocyte-platelet adhesion index at T2 (0.023 ± 0.005 vs 0.063 ± 0.013, P = 0.0092) and T4 (0.031 ± 0.003 vs 0.055 ± 0.005, P = 0.0017), TAT complexes at T2 (27.175 ± 5.967 vs 86.592 ± 5.415, P = 0.0005) and T3 (26.977 ± 2.468 vs 45.146 ± 4.365, P = 0.0041), F1+2 fragments at T2 (2.222 ± 0.226 vs 4.249 ± 0.292, P = 0.0009), and sP-selectin at T3 (115.17 ± 19.623 vs 169.554 ± 19.709, P = 0.0703) and T4 (108.542 ± 6.429 vs 140.799 ± 14.771, P = 0.0833). In summary, the Synergy exhibited a lower post-operative activation of blood coagulation, together with a reduced interaction between circulating monocytes and platelets.

Perceval S sutureless aortic valve prosthesis implantation via a right anterior minithoracotomy.

BACKGROUND This study reports the single center experience on minimally invasive aortic valve replacement (MIAVR), performed through a right anterior minithoracotomy or ministernotomy (MS). METHODS Eight hundred and fifty-three patients, who underwent MIAVR from 2002 to 2014, were retrospectively analyzed. Survival was evaluated using the Kaplan-Meier method. The Cox multivariable proportional hazards regression model was developed to identify independent predictors of follow-up mortality. RESULTS Median age was 73.8, and 405 (47.5%) of patients were female. The overall 30-day mortality was 1.9%. Four hundred and forty-three (51.9%) and 368 (43.1%) patients received biological and sutureless prostheses, respectively. Median cardiopulmonary bypass time and aortic cross-clamping time were 108 and 75 minutes, respectively. Nineteen (2.2%) cases required conversion to full median sternotomy. Thirty-seven (4.3%) patients required re-exploration for bleeding. Perioperative stroke occurred in 15 (1.8%) patients, while transient ischemic attack occurred postoperative in 11 (1.3%). New onset atrial fibrillation was reported for 243 (28.5%) patients. After a median follow-up of 29.1 months (2,676.0 patient-years), survival rates at 1 and 5 years were 96%±1% and 80%±3%, respectively. Cox multivariable analysis showed that advanced age, history of cardiac arrhythmia, preoperative chronic renal failure, MS approach, prolonged mechanical ventilation and hospital stay as well as wound revision were associated with higher mortality. CONCLUSIONS MIAVR via both approaches is safe and feasible with excellent outcomes, and is associated with low conversion rate and low perioperative morbidity. Long term survival is at least comparable to that reported for conventional sternotomy AVR.

Hypothesis-free secretome analysis of thoracic aortic aneurysm reinforces the central role of TGF-β cascade in patients with bicuspid aortic valve

The rapid development and refinement of techniques over the past decade have led to the realization that a minimally invasive approach enables aortic valve surgery to be performed with results, at the very least, equivalent to those of traditional (open) valve surgery done in experienced centres. Minimally invasive aortic valve replacement (MIAVR) has now evolved into a safe, efficient treatment option providing greater patient satisfaction and fewer complications. For rapidly ageing population of industrialized countries, aortic valve replacement (AVR) has become the most frequent heart valve surgery. However, transcatheter aortic valve implantation techniques and sutureless aortic valve prostheses recently introduced into clinical practice are challenging now the results of MIAVR in certain high surgical risk patients. Right anterior minithoracotomy results in excellent exposure and a safe conduct of AVR. The minithoracotomy is performed via the second intercostal space with a 6-7 cm long skin incision and no bone transection. After direct aortic and peripheral venous cannulation, aortic valve is exposed in a conventional manner, and further conduct of the intervention is not different from the sutureless AVR in median sternotomy. Herein, we discuss the indications, surgical technique and initial results of sutureless AVR through right anterior minithoracotomy.

Sutureless Aortic Valve Replacement for Aortic Incompetence

BACKGROUND Ascending thoracic aortic aneurysm (ATAA) is a major cause of morbidity and mortality worldwide. The pathogenesis of medial degeneration of the aorta remains undefined. High-throughput secretome analysis by mass spectrometry may be useful to elucidate the molecular mechanisms involved in aneurysm formation as well as to identify biomarkers for early diagnosis or targets of therapy. The purpose of the present study was to analyze the secreted/released proteins from ATAA specimens of both tricuspid aortic valve (TAV) and bicuspid aortic valve (BAV) patients. METHODS Aortic specimens were collected from patients undergoing elective surgery and requiring graft replacement of the ascending aorta. Each sample of the ascending aortic aneurysm, 4 BAV (3 males; aged 53.5±11.4 years) and 4 TAV (1 male; 78±7.5 years), was incubated for 24h in serum-free medium. Released proteins were digested with trypsin. Peptide mixtures were fractioned by nano-high performance liquid chromatography and analyzed by mass spectrometry. Following identification of differentially expressed proteins, quantitative real time polymerase chain reaction (qRT-PCR) analysis was performed. RESULTS The comparison between the proteins released from BAV and TAV aneurysmatic tissues showed significantly diverging expression fingerprints in the two groups of patients. Bioinformatics analysis revealed 38 differentially released proteins; in particular 7 proteins were down-regulated while 31 were up-regulated in BAV with respect to TAV. Most of the proteins that were up-released in BAV were related to the activation of transforming growth factor (TGF)-β signaling. Latent TGF-β binding protein 4 (LTBP4) exhibited one of the highest significant under-expressions (10-fold change) in BAV secretomes with respect to TAV. qRT-PCR analysis validated this significant difference at LTBP4 gene level (BAV: 1.03±0.9 vs TAV: 3.6±3.2; p<0.05). CONCLUSION Hypothesis-free secretome profiling clearly showed diverging expression fingerprints in the ATAA of TAV and BAV patients, confirming the crucial role of TGF-β signaling in modulating ATAA development in bicuspid patients.